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Pioglitazone is associated with a small increased risk of bladder cancer; do not use in patients with active bladder cancer, a history of bladder cancer or unexplained haematuria. Before starting pioglitazone, review known risk factors for bladder cancer; use in the elderly should be very carefully considered as risk of bladder cancer increases with age. In the elderly, start with the lowest possible dose and monitor very carefully due also to the risk of heart failure. In all patients review treatment after 3-6 months and discontinue if there is no benefit derived. For more details see Drug Safety Update, August 2011.

Pioglitazone is contraindicated in patients with cardiac failure. Pioglitazone can cause fluid retention, which may exacerbate or precipitate heart failure. When treating patients who have at least one risk factor for development of congestive heart failure, start with the lowest available dose and increase the dose gradually. Patients should be observed for signs and symptoms of heart failure, weight gain or oedema, particularly those with reduced cardiac reserve. Those receiving concurrent insulin or sulphonylurea are at particular risk. Treatment should be stopped if any deterioration in cardiac status occurs.

Prescribing notes

AcarboseConsider for a person unable to use other oral glucose-lowering medications. Acarbose delays the digestion and absorption of starch and sucrose. It has a small but significant effect in lowering blood glucose and is used either on its own or as an adjunct to metformin or to sulphonylureas when they prove inadequate. Flatulence deters some from using acarbose although this side effect tends to decrease with time. Timing of doses is crucial; tablets should be chewed or swallowed whole with the first mouthful of food.

RepaglinideConsider offering to a person with an erratic lifestyle. Repaglinide stimulates insulin release. It has a rapid onset of action and a short duration of activity. It only needs to be taken at mealtimes (shortly before each main meal). This makes it a useful alternative to sulfonylureas for patients with irregular meal patterns or lifestyles (where hypoglycaemia would otherwise pose a risk).

PioglitazoneConsider as part of a dual or triple therapy regime. NICE has advised that the use of a thiazolidinedione is not recommended except for patients unable to tolerate the metformin and sulfonylurea combination or where either are contraindicated. NICE advises not to use pioglitazone in patients with heart failure or at high risk of fractures.

On this website you will now see four icons for these resources rather than two. Please use BNF Legacy or BNF for Children Legacy as these will take you to the original format of the online publications which do not have any errors or omissions.